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Upon completion, please send this form to: / In regards to:
Client Name:
Client ID or SSN:

Authorization for Release of
Protected Health Information

Please fill in ALL blanks

I [ ] hereby authorize the use or disclosure of my health information as described in this authorization.

  1. Specific person/organization (or class of persons) authorized to provide the information:
  1. Specific person/organization (or class of persons) authorized to receive and use the information:
  1. Specific and meaningful description of the information:

Please describe the information you wish KHPA and DCF to disclose, for example:

Written, electronic and oral information related to eligibility for benefits for the time period commencing on ______date and continuing through ______date.

Written, electronic and oral information including claims, reports, and other documents related to claims for benefits for an injury or illness commencing on ____ date and continuing through ______date.

Written, electronic and oral information relating to payment or lack of payment of benefits to [name of health care provider] for services rendered on ______date.

Other: ______

______

  1. Purpose of the request:

Please state the purpose of the request below. [For example, to discuss my benefits with the Benefits Administration staff so that I can better understand my benefits.] If you do not wish to state a purpose, please state, “At the request of the individual.” ______

______

  1. Right to Revoke: I understand that I have the right to revoke this authorization at any time by notifying the person/organization listed in number 1 above in writing at [list address to which revocation must be delivered]. I understand that the revocation is only effective after it is received and logged by the person/organization listed in number 1 above. I understand that any use or disclosure made prior to the revocation under this authorization will not be affected by a revocation.
  2. I understand that after this information is disclosed, federal law might not protect it and the recipient might disclose it again.
  3. I understand that I am entitled to receive a copy of this authorization.
  4. I understand that this authorization will expire on (insert an expiration date. If no date is inserted, the authorization will expire 12 months from the date entered in 9).

9.KHPA will not condition treatment, payment, enrollment or eligibility for health plan benefits on receipt of an authorization.

______

Signature of IndividualDate

If a Personal Representative executes this form, that Representative warrants that he/she has authority to sign the form on the basis of:

______

______

______

This authorization reflects the requirements of 45 CFR § 164.508 (August 14, 2002).

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